Provider Demographics
NPI:1932233079
Name:MIKKELSEN, KIM RAE (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:RAE
Last Name:MIKKELSEN
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-1477
Mailing Address - Country:US
Mailing Address - Phone:919-477-3642
Mailing Address - Fax:
Practice Address - Street 1:115 MARKET ST
Practice Address - Street 2:SUITE 201
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-3251
Practice Address - Country:US
Practice Address - Phone:919-560-5600
Practice Address - Fax:919-560-3018
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YP2500X, 104100000X, 171M00000X
NCC0037281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC139CPOtherBLUE CROSS